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Professional Development

Annual Scientific Assembly Online Registration

Name (As you would like it to appear on badge)

First Last

Check Applicable

Fellow

Registrant T Shirt Size (Adult Sizes)

AAFP Member #

Cell Phone

Email(Required)

Clinic or Organization Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

While in Destin, I will be staying:

Registration Type (Before July 1)

MAFP Active Member ($525)

MAFP Life Member ($425)

Non-MAFP Member ($625)

Family Medicine Resident ($0)

Medical Student ($0)

July 1st

Guest/Spouse

Price: $200.00

Guest registration is $200 for adults or children 18 and over. Includes admission to Exhibit Hall, Family Fun Night, Devotional, Yoga, Awards Luncheon, Bingo, Convention Tshirt.

Guest Names, TShirt Size (Adult S – 3XL)

Children’s Names and Ages

Bracelets will be given at regis, please wear to events

Additional Items

Sunday, July 16

MEMBER - KSA: Care of Older Adults - (1 - 5p)

Price: $125.00

NON-MEMBER - KSA: Care of Older Adults - (1 - 5p)

Price: $250.00

Camp MAFP Family Fun Night - (6 - 7:30p)

Price: $0.00

Included with Registration

Monday, July 17

Spouse Bingo - 10a

Price: $0.00

Included with Registration. Kids are welcome but will receive kids prize.

Golf Tournament at The Raven - (2p)

Price: $120.00

Shotgun start

Family Crab Hunt (Evening)

Price: $0.00

Included with Registration

Tuesday, July 18

MAFP Awards Lunch (Members Only) - 12:30p

Price: $0.00

Included with Registration

MAFP Awards Lunch EXTRA Tickets - 12:30p

Price: $50.00

MAFP Split the Pot Drawing

Price: $100.00

If I win, please donate this amount to the Foundation

Enter amount you'd like donated to the foundation

Laser Tag - Included with Registration(6 - 9 pm)

Price: $0.00

Included with Registration (6-7:30 for ages 14 & under, 7:30-9 for ages 15 and older)

EXTRA ITEMS: The items below will be waiting for you at the Registration Desk.

Sponsor a Student

Price: $50.00

Your contribution will directly help offset the cost of medical students’ rooms & convention expenses. You will receive a Student Supporter ribbon.

Water Color Paint

Price: $50.00

12 x 15 Family Medicine print, signed and numbered by artist Katie Erickson. (Special price for Annual Meeting attendees only.)

Images Book

Price: $50.00

Images in MS Medicine book by family physician Dr. Luke Lampton

Extra Small (2-4)

Price: $20.00

Small (6-8)

Price: $20.00

Medium (10-12)

Price: $20.00

Large (12-14)

Price: $20.00

Adult (S)

Price: $20.00

Adult (M)

Price: $20.00

Adult (L)

Price: $20.00

Adult (XL)

Price: $20.00

Adult (2XL)

Price: $20.00

Adult (3XL)

Price: $20.00

Total

Credit Card

Card Details

Cardholder Name